Medicare’s New Chronic Care Management Codes for MDs: Clinical IT and Other Requirements

One physician expert lays out the opportunities and challenges inherent in Medicare’s new CPT codes for chronic care management

As of January 1, the Medicare program began paying physicians for chronic care management, authorizing a monthly payment per Medicare enrollee (estimated to average out nationally at approximately $42.60) to every Medicare-participating physician who fulfills a set of requirements for the care of patients with multiple chronic illnesses.

Any physician seeking to participate (and certain physician assistants and nurse practitioners are also eligible to participate) needs to be the primary care physician for a patient with two or more chronic conditions, and needs to meet numerous requirements around using an electronic health record (EHR) for documentation, sharing continuity of care documents (CCDs) with physician and other clinician colleagues, and provide care coordination services to her or his patient every month. The American College of Physicians (ACP), the national professional association for internal medicine specialists, has provided a succinct and helpful summary on the subject.

One physician executive who is knowledgeable about the topic is Ron Ritchey, M.D. Dr. Ritchey is the chief medical officer at eQHealth Solutions, The Medicare QIO for Louisiana (every state has a quality improvement organization interfacing between the Medicare program and providers, and eQHealth Solutions is the designated QIO in Louisiana).

A not-for-profit non-governmental organization, eQHealth Solutions functions both in its core QIO capacity, and also has commercialized several IT solutions for providers in areas around population health and care management. Dr. Ritchey spoke recently with HCI Editor-in-Chief Mark Hagland regarding the new reimbursement opportunity around care management. Below are excerpts from that interview.

What is the policy context of the new Medicare physician reimbursement opportunity?

Yes, Medicare has for some time come to the conclusion that they have a lot of members who have multiple diseases, and that much of their cost is coming out of that. And through a number of demonstrations, they’re coming to the conclusion that primary care physicians’ relationships with those patients is a critical issue in reducing care costs. This coordinates with the concepts of patient-centered medical homes, electronic health records, and interoperability. Historically, Medicare has been a payer of evaluation and management codes. In other words, a patient sees a physician, there’s a laying on of hands, diagnosis and treatment take place, and then a bill drops. Now recently, at Medicare, they’ve been moving towards the recognition that some necessary services haven’t taken place because there’s no mechanism for them. And these services are very important—a lot of coordinated services were not being reimbursed, and therefore, very little effort was put into them; the physicians were focused on the management and evaluation component.

Ron Ritchey, M.D.

So Medicare decided to pay for a transitions care code, it’s a CPT code. That was touching their toes into the water. Now, beginning January 1, they’ve come out with this chronic condition management, or CCM, code, 9940 is the CPT. So basically, the physician has the responsibility to identify a qualified Medicare beneficiary—someone with at least two identified chronic conditions. Someone has to explain the process, the patient has to provide consent and you have to maintain that information on consent in your electronic record. And then you have to meet a number of conditions to qualify. It averages about $40 across the country; and it’s one payment per month. And it can only be billed by one physician per month.

How many physicians are actively documenting their chronic care management now, a couple of weeks into the new year?

Right now, it’s very few. Most don’t understand it, and many who are aware of it don’t have enough depth of understanding to feel comfortable doing it, and of those who do understand it, only a few of them have developed the mechanism or infrastructure needed. So not many have done it yet.

What process and IT requirements do physicians need to fulfill in order to participate?

First, let me give you a broad overview. This is an opportunity to bring in a significant amount of new money into practice without having to expend an unreasonable amount of effort. I think many physicians in a solo shop or small practice may find the regulations a bit burdensome. They might want to partner with a vendor to have the vendor to provide some backup services.

There are about 50 pages on this in the federal register. And even with those 50 pages, there’s still a certain amount of ambiguity that remains to be ironed out. So there are three steps: first, identify the qualified beneficiaries and get their consent. Second, meet the technology requirements, which are part of a major initiative of Medicare’s around chronic record management. Third, the practitioner has to execute the chronic care services to document it to Medicare.

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Please correct me if I'm wrong. So are physicians interested in this or are they thinking this is just more work for very little money? I've already seen companies provide software solutions to help with this that cost between $28 and $35/month, leaving very little for the physician?